Creation of space of retzius

This segment of the video shows creation of space of Retzius and visualization of preperitoneal fat herniating through the obturator defect. all adhesions between the peritoneum and the anterior abdominal wall are lysed to expose the space of Retzius. A segment of preperitoneal fat is seen prolapsing through an opening in the pelvic wall.

On reduction, it is found to be an obturator hernia containing preperitoneal fat. This is a type I obturator hernia. Dissection in this area needs to be meticulous to avoid vascular and nerve injury.

The obturator hernia is a rare hernia which occurs through the obturator foramen, which is located between the pectineus and obturator externus muscles. It is the commonest of all pelvic hernias known and is commonly called the “little old lady’s hernia.” It is most commonly seen in multiparous, thin, frail, old women.

The obturator hernia is classified into three types, type I being an enlarged obturator defect with herniation of preperitoneal fat. Type II contains a dimple of peritoneum but no visceral content. And type III contains viscera, of which the small bowel is the commonest content reported. The appendix, Meckel’s diverticulum, omentum, ovary, fallopian tube, and even the uterus are some of the other contents reported. Once dissected it is easy to visualize the defect with the obturator nerves and vessels exiting the pelvis through it.

Chronic pelvic pain is one of the early signs of an obturator hernia. However, it is nonspecific, often causing a delay in diagnosis. Inner thigh neuralgias may occur and can be demonstrated on the Howship-Romberg sign, which is pathognomonic of the condition.

Bowel obstruction is the commonest form of presentation. 90% of patients present and are diagnosed with acute bowel obstruction. It is associated with high morbidity and a mortality of nearly 50% due to rapid progression to strangulation and gangrene of the gut in the rigid obturator canal.

A CECT scan is the investigation of choice and has improved the preoperative diagnostic accuracy from 43% to 90%. Surgery is the only treatment for this condition. The preperitoneal approach, as in the TEP, offers the distinct advantage of detecting these hernias, even when asymptomatic. The TEP mesh repair provides adequate cover to the obturator defect too.